An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Encourage the client to lie as still as possible during the assessment.

Ask the client how often episodes of sundowning are experienced.

Assist the client with values clarification about end-of-life care options.

Question the client about the frequency of falls in recent months.

Answer and Explanation

The Correct Answer is D

Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.

Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.

Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.

Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

Choice A Reason: A BMI of 28 kg/m² is considered overweight and is a modifiable risk factor for type 2 diabetes mellitus. Weight loss through diet and exercise can reduce the risk.

Choice B Reason: An HDL level of 43 mg/dL (1.11 mmol/L) is slightly below the recommended range and is a modifiable risk factor. Increasing HDL can be achieved through lifestyle changes such as exercise and dietary adjustments.

Choice C Reason: Having a sister with type 2 diabetes mellitus is a non-modifiable risk factor as it is related to genetic predisposition.

Choice D Reason: Occupational fume exposure is generally considered unrelated to the development of type 2 diabetes mellitus.

Choice E Reason: Cannabis use is typically unrelated to type 2 diabetes mellitus, though research on its long-term metabolic effects is ongoing.

Normal Ranges:

BMI: 18.5 to 24.9 kg/m² (normal)
HDL (High-Density Lipoprotein): Greater than 45 mg/dL (Greater than 1.15 mmol/L)
LDL (Low-Density Lipoprotein): Less than 130 mg/dL (Less than 3.4 mmol/L)
Fasting Blood Glucose: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)

A. Teach the client to use an incentive spirometer every 2 hours while awake. B. Administer low molecular weight heparin as prescribed. C. Assess the pain level and medicate as needed, as prescribed. D. Maintain sequential compression devices while in bed. E. Remove the urinary catheter as soon as possible and encourage voiding.

Correct Answer is ["A","E"]

Explanation

The correct answer is: A. Teach the client to use an incentive spirometer every 2 hours while awake and E. Remove the urinary catheter as soon as possible and encourage voiding.

Choice A reason:

Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent postoperative pulmonary complications such as pneumonia. This intervention promotes lung expansion and clears secretions, reducing the risk of infection.

Choice B reason:

Administering low molecular weight heparin as prescribed is important for preventing deep vein thrombosis (DVT) and pulmonary embolism, but it does not directly reduce the risk of infection.

Choice C reason:

Assessing the pain level and medicating as needed is crucial for patient comfort and mobility, but it does not directly address infection prevention. Effective pain management can indirectly support recovery by enabling better mobility and respiratory function.

Choice D reason:

Maintaining sequential compression devices while in bed is aimed at preventing DVT, not infections. These devices help improve blood circulation and reduce the risk of blood clots.

Choice E reason:

Removing the urinary catheter as soon as possible and encouraging voiding reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal of the catheter minimizes the duration of exposure to potential pathogens, thereby reducing infection risk.

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An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Review of History, Physical, and Laboratory Results Based on the findings, indicate whether each represents a modifiable risk factor, a non-modifiable risk factor, or is unrelated to type 2 diabetes mellitus.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}

Explanation

An older adult client is admitted for the repair of a broken hip. To reduce the risk of infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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